Further reductions in tobacco use calls for increased readiness and capacity of primary care physicians to treat tobacco dependence. However, primary care providers face considerable pressure and logistical challenges to address multiple preventive care concerns during brief office visits with their patients. Efforts to encourage adaptation of well-established clinical practice guidelines must address the tension between time limitations and best practices. In this study, we will test the hypothesis that adaptation of the current cessation guideline in primary care settings will be improved through use of a simulation tool that can help providers compare viable alternative strategies and consider the relative impact of these strategies on their patients and their practice. The proposed tool will simulate the implementation of key processes of evidence-based tobacco treatment, as identified in the current PHS Guideline. System dynamics modeling techniques will be used to develop, test, and validate the output of the simulation tool. System dynamics models are mathematical simulations of dynamic change. System dynamics modeling has been demonstrated to promote deeper understanding of complex human and organizational problems, actions, and policies to address them. Our proposed study will be nested within Queens Quits!, an on-going project funded by the New York State Department of Health that is designed to disseminate and implement the PHS Guideline to health care providers in the Borough of Queens. The specific aims of the proposed research are to develop a system dynamics simulation tool as a decision aid for promoting in-depth understanding about how best to implement currently recommended the clinical guidelines for the treatment of tobacco use and dependence at the practice level, and, second, to conduct a formative assessment of the simulation tool with 30 primary care practices located in ethnically diverse, urban communities. Our formative assessment will examine: (1) feasibility and acceptability of using the simulation tool in an academic detailing intervention, (2) changes in individual provider attitudes about and practices in tobacco treatment, and (3) implementation of new or improved office systems to improve tobacco treatment at the practice level. We hypothesize that system dynamics modeling of the practice environment will promote deeper understanding of and greater impetus to implement the PHS Guideline. PUBLIC HEALTH RELEVANCE: Tobacco use is the leading preventable cause of premature death in the United States. Each year, more than 440, 000 Americans die of tobacco-related disease, accounting for 1 in every 5 deaths. Cigarette smoking is responsible for more than 30 percent of cancer deaths annually in the United States. Smoking also contributes substantially to deaths from heart disease, stroke, and chronic obstructive pulmonary disease. From 1995 to 1999, estimated annual smoking-attributable economic costs in the United States were $75.5 billion for direct medical care for adults and $81.9 billion for lost productivity. Brief counseling intervention by primary care providers has been shown to effectively promote tobacco use cessation, yet many physicians do not consistently adhere to this practice for all patients at each appointment. The proposed study would develop and test an innovative intervention to assist primary care physicians who serve ethnically diverse, urban communities implement PHS evidence- based practices for tobacco dependence treatment.